Despite a reduction in smoking prevalence in the general United States adult population over the past 4 decades, the prevalence of smoking remains high among low income adults and low income veterans of the United States military. Despite the highly-advanced, population-based approach to tobacco control in the Veterans Administration (VHA) health care system, low income smokers remain difficult to treat. A pervasive, nationwide lack of approach to smoking as a chronic disease, with high relapse rates and multiple quit attempts per smoker even in the best of circumstances, is a critical deficit in the current standard of care for low income smokers, who are even less likely than wealthier individuals to quit smoking, and more likely to relapse when they do quit. The goal of this application is to examine the effectiveness of an intervention designed to reduce smoking in low income adults within a regional United States Veterans Administration (VHA) health care system. We propose a pro-active, personalized, coordinated system of care (Connect to Quit (CTQ)) which is rooted in the Chronic Care Model. CTQ treats smoking as a chronic condition that, like hypertension or diabetes, requires long term treatment with appropriate combinations of behavioral therapy and pharmacotherapy. CTQ will be evaluated in the context of 3 VA Pittsburgh Healthcare System (VAPHS) medical practices which care for ~2,400 low-income smokers, 93% of whom report an annual household income below $36,000 (27% make < $10K; 37% make from $10-$19,999K; 23% make from $20-$29,999K; and only 13% make > $30,000). Approximately 40 Primary Care Providers (PCPs, including non-physicians) in VAPHS (and their low income patients making < $36,000/year) will be invited to be randomized to either CTQ or Usual Care (UC, existing VHA services, without additional CTQ services). Desire to quit smoking is not required for participation in the study, as the point of CTQ is to engage smokers at every level of readiness to quit. Approximately 480 low income smokers in each group are expected to enroll and be followed for a minimum of 2 years. Investigators will measure abstinence (biochemically-validated 30 day point-prevalence) at the end of 2 years and over a 2-year period (measured every 6 months). Direct and indirect costs of care will be assessed to calculate the incremental cost per successful quit of CTQ vs. UC. Investigators will explore mediating effects of process measures related to treatment utilization and behavioral processes (of enrolled patients and providers) on the impact of CTQ. This proposal is led by Dr. Tindle, a new investigator, and represents a collaborative effort by investigators with complementary expertise, experience, and positioning to execute the study. The conservatively-estimated impact of CTQ to increase abstinence by ~5% above and beyond UC (representing a 50-100% increase in cessation) at two years would result in ~50,000 fewer low income smokers in the national VA population of low income veterans, and ~300,000 fewer if projected nationally to all low-income smokers. PUBLIC HEALTH RELEVANCE: Smoking is the leading preventable cause of disease and death in the United States and in the world, yet smoking remains common among people with low income, such as low income veterans of the United States military. This project will test how well a program called Connect to Quit helps low income veterans quit smoking. The program treats smoking as an ongoing health condition that, like high blood pressure or diabetes, needs a combination of ongoing support, classes, and medication. The results of this project will improve our understanding of how to help low income veterans successfully quit smoking.